Every finding on record at Sure Care Health Care Services

The following reflects the findings of the California Department of Public Health during the Recertification survey at this location. 1109 West San Bernardino Road, Suite 200 Covina, CA 91722. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: Surveyor ID: Health Facilities Evaluator Nurse: Surveyor ID: 22303 Active census: 11 Sample size: 7 Home visits: 3

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) staff failed to review all medications the patient is taking by reconciling the current medications with the medication profile for 3 out of 7 sample patients (Patients 1, 2, and 4). This deficient practice had the potential to place the patients at risk for medication errors and serious adverse effects. a. A review of Patient 1's Plan of Care (POC) for the certification period from 2/16/23 through 4/16/23, indicated the Start of Care date was 2/16/23, with diagnosis that included urinary tract infection (infection in the kidneys, bladder and urethra). The POC indicated the Skilled Nurse (SN) was to visit three times a week for two weeks, twice a week for one week, once a week for six weeks, to perform skilled observation and assessment of vital signs and all body systems and medication and dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 2/25/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS (director of patient care services). Patient 1 was alert and oriented and lying in bed. At 11:20 a.m., a review was conducted of Patient 1's current medications comparing with the medication profile provided by the agency. It was observed Patient 1 had a bottle of Trazadone 50 mg (milligrams) one tab at bedtime. This particular medication was not included in the medication profile. At 11:35 a.m., during an interview with Caregiver 1, she stated the patient was taking Trazadone 50 mg one tab at bed time for over two months now. b. A review of Patient 2's Plan of Care (POC) for the certification period from 1/27/23 through 3/27/23, indicated the Start of Care date was 1/27/23, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). The POC indicated the Skilled Nurse (SN) was to provide an initial visit, to perform skilled observation and assessment of vital signs and all body systems and medication and dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 2/25/23, at 12:30 p.m., a home visit was conducted at Patient 2's residence with DPCS (director of patient care services). Patient 2 was alert and oriented and sitting on her couch. At 1 p.m., a review was conducted of Patient 2's current medications comparing with the medication profile provided by the agency. It was observed Patient 2 had a bottle of Eletimide 10 mg (milligrams) one tab at bedtime. This particular medication was not included in the medication profile. At 1:15 p.m., during an interview with Caregiver 2, she stated the patient was taking Eletimide 10 mg one tab at bed time for over a month now. On 2/26/23, at 12 p.m., during an interview with DPCS, she stated she missed checking Patient 1 and 2's medications and asking their family members how often medications were given during her visits. A review of the agency's policy titled "Medication Profile" indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications. c. A review of Patient 4's start of care (SOC) date of 1/11/2023 and certification period of 1/11/23 to 3/11/23, indicated a diagnosis of unspecified open wound of scalp. A review of Patient 4's plan of care (POC) and skilled nursing orders dated from 1/11/23 to 3/11/23, to include an order for the skilled nurse visit of once a week for thirteen weeks to observe/assess all body systems, with emphasis on the integumentary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety and pain management as applicable and to perform wound care to scalp wound daily as ordered by the physician. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/25/23, at 10:00 a.m., Patient 4 is comfortably sitting in her reclining chair and in no apparent distress. Patient 4 stated that she does not have any concerns at this time and stated although she has a caregiver, she still prepares her own medications in the pill box. A review of patient 4’s home health folder was done with no active medication list included in it. Medication reconciliation was conducted with the DPCS and the following discrepancies were noted: Furosemide 20milligrams (mg) 1 tablet by mouth once a day not listed in active medication list, (medication is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease). Alendronate 10 mg has no physician’s order and not listed in active medication list, (medication is used to prevent and treat osteoporosis (thinning of the bone). Nitroglycerin 0.4 mg with written instruction in the active medication list to take as 1 tablet sublingually every 15 minutes times 3 doses as needed for chest pain in compared with the medication label written instruction to take as to take 1 tablet under the tongue and allow to dissolve one time, may repeat one time in 5 minutes then call 911. Metoprolol 25 mg listed in the active medication list as oral capsule extended release 24 hours sprinkle 25 mg to take two times a day one-half capsule but available on hand is Metoprolol 25 mg in tablet form. (Medication is used to treat high blood pressure, chest pain (angina), and heart failure. This may lower the risk of death after a heart attack). Pro Air Inhalation Aerosol Solution 90 microgram (mcg) listed in the active medication list instruction to take once a day 1 puff as needed for wheezing compare with the medication label as written to take 2 puffs every 4 to 6 hours as needed for wheezing. At 10:30 am, during an interview with patient 4, she stated that the Alendronate medication was prescribed by her physician from her last visit approximately 2 weeks ago and she forgot to notify her nurse regarding that. During a concurrent review of patient 4’s clinical records and interview with the DPCS on 2/25/23, at 10:00 a.m., there was no documented evidence of physician’s order or communication notes of Alendronate medication. DPCS stated that she does not know why the visiting skilled nurse did not coordinate with the agency and notify the physician regarding the alendronate medication. DPCS stated that visiting skilled nurses should conduct medication reconciliation on each visit to determine any discrepancies. She further stated that patients should have an active and current medication list in their home health folder and visiting nurse should ensure that medication list is current and updated.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the visiting nurse failed to ensure care followed the written plan of care for three of 7 patients (Patients 1, 4, and 5). For Patient 1, the patient had a Stage II sacral pressure sore . The visiting nurse failed to do a wound assessment every visit. For Patient 4, the patient has a wound on scalp. The visiting nurse failed to perform wound assessment during the initial visit. For Patient 5, the patient has colostomy . The stoma was not assessed by the visiting nurse during the initial and the following visits. This deficient practice placed the patient at a potential risk for delayed wound healing, a decline in the condition of the wound, and possible risk for infection on the wound sites. A review of Patient 1's Plan of Care (POC) for the certification period from 2/16/23 through 4/16/23, indicated the Start of Care date was 2/16/23, with diagnosis that included urinary tract infection (infection in the kidneys, bladder and urethra). The POC indicated the Skilled Nurse (SN) was to visit three times a week for two weeks, twice a week for one week, once a week for six weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing intervention was to provide wound care to Stage II sacral pressure sore as follows: cleanse with normal saline, pat dry, apply Calmoseptne and cover with Tegaderm dressing. On 2/25/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS (director of patient care services). Patient 1 was alert and oriented and lying in bed. Patient 1 had a Stage II sacral pressure sore with no drainage or odor. A review of Patient 1's Nurse Progress Notes dated 2/17 and 2/18/23, indicated no documented evidence the skilled nurse (SN) was doing a wound assessment on Patient 1's Stage II sacral pressure sore. On 2/26/23, at 11 a.m., during an interview with the DPCS (director of nursing care services), she stated the visiting nurse should be assessing the patient's open wound on every visits. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits. b. A review of Patient 4's start of care (SOC) date of 1/11/2023 and certification period of 1/11/23 to 3/11/23, indicated a diagnosis of unspecified open wound of scalp. A review of Patient 4's plan of care (POC) and skilled nursing orders dated from 1/11/23 to 3/11/23, to include an order for the skilled nurse visit of once a week for thirteen weeks to observe/assess all body systems, with emphasis on the integumentary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety and pain management as applicable and to perform wound care to scalp wound daily as ordered by the physician. A review of Patient 4’s comprehensive nursing assessment dated 1/11/23, indicated no documentation of assessment on wound located at scalp. c. A review of Patient 5's start of care (SOC) date of 2/3/23 and certification period of 2/3/23 to 4/3/23, indicated a diagnosis of diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar) and on colostomy status (An opening into the colon from the outside of the body and provides a new path for waste material to leave the body after part of the colon has been removed). A review of Patient 5's plan of care (POC) and skilled nursing orders dated from 2/3/23 to 4/3/23, to include an order for the skilled nurse visit of four times a week for two weeks then once a week for five weeks to observe/assess all body systems, with emphasis on the genito-urinary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety, pain management as applicable and to administer IV antibiotics via midline (is an 8-12 centimeter (cm) catheter inserted in the upper arm with the tip located just below the underarm). A review of Patient 5’s clinical records indicated that the agency supplies DME (Durable Medical Equipment) which includes colostomy bags. A review of Patient 5's comprehensive nursing assessment dated 2/3/23, indicated no documented evidence the skilled nurse (SN) performed stoma (is an opening on the abdomen that can be connected to the digestive system to allow waste (feces) to be diverted out of the body and it looks like a small, pinkish, circular piece of flesh that is sewn to the body) assessment during visit. During an interview with the Director of Patient Care Services (DPCS) on 2/26/23, at 12:30p.m., she stated that they have a new electronic medical record system started January of 2023 and she is still getting familiar with it, she stated that she does not know which section she can put her wound assessments for patients. She stated that she should have also include a completed assessments on wounds for accurate monitoring of improvement and should perform an assessment of patients who have colostomy bag to ensure that it is free from infection, and it is patent.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure prescribed wound treatments were administered and physician’s orders were obtained from the physician for three of 7 sampled patients (Patients 1, 4 and 5). For Patient 1, the skilled nurse failed to ensure that prescribed wound treatments were administer to patient’s stage II sacral pressure sore by the caregiver For Patient 4, the skilled nurse failed to obtain a physician’s order for Alendronate Sodium (a medication to prevent and treat osteoporosis (thinning of the bone). For Patient 5, the skilled nurse failed to obtain a physician’s order for Heparin flush (medication is used to keep intravenous (access through vein) catheters open and flowing freely, it also helps to keep blood flowing smoothly and from clotting in the catheter by making a certain natural substance in the body (anti-clotting protein) work better and is known as an anticoagulant). These deficient practices place the patients at a potential risk for inaccurate delivery of nursing services that could affect his/her overall health status. A review of Patient 1's Plan of Care (POC) for the certification period from 2/16/23 through 4/16/23, indicated the Start of Care date was 2/16/23, with diagnosis that included urinary tract infection (infection in the kidneys, bladder and urethra). The POC indicated the Skilled Nurse (SN) was to visit three times a week for two weeks, twice a week for one week, once a week for six weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing intervention was to provide wound care to Stage II sacral pressure sore as follows: cleanse with normal saline, pat dry, apply Calmoseptne and cover with Tegaderm dressing. On 2/25/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS (director of patient care services). Patient 1 was alert and oriented and lying in bed. Patient 1 had a Stage II sacral pressure sore with no drainage or odor. When Caregiver 1 was asked on how she provide wound care as instructed by the visiting nurse, she stated she was instructed by the visting nurse to do the following:, cleanse with Normal Saline, pat dry and apply Calmoseptine ointment and leave open to air. At 11:30 a.m., during an interview with the DPCS, she stated the visiting nurse should have instructed Caregiver 1 to apply Tegaderm dressing after applying the Calmoseptine oitment to patient's open wound as ordered. b. A review of Patient 4's start of care (SOC) date of 1/11/2023 and certification period of 1/11/23 to 3/11/23, indicated a diagnosis of unspecified open wound of scalp. A review of Patient 4's plan of care (POC) and skilled nursing orders dated from 1/11/23 to 3/11/23, to include an order for the skilled nurse visit of once a week for thirteen weeks to observe/assess all body systems, with emphasis on the integumentary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety and pain management as applicable and to perform wound care to scalp wound daily as ordered by the physician. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/25/23, at 10:00 a.m., Patient 4 is comfortably sitting in her reclining chair and in no apparent distress. Patient 4 stated that she does not have any concerns at this time and stated although she has a caregiver, she still prepares her own medications in the pill box. Medication reconciliation was conducted with the DPCS, a medication labeled in a bottle as Alendronate Sodium was not in patient 4’s active medication list. Patient 4 stated that the medication was prescribed to her by her doctor about two weeks ago and she forgot to tell it to the visiting nurse. DPCS stated that the visiting nurse should conduct a medication reconciliation on each visit and should have communicated it with the doctor to update an order to patient 4’s active medication list. c. A review of Patient 5's start of care (SOC) date of 2/3/23 and certification period of 2/3/23 to 4/3/23, indicated a diagnosis of diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar). A review of Patient 5's plan of care (POC) and skilled nursing orders dated from 2/3/23 to 4/3/23, to include an order for the skilled nurse visit of four times a week for two weeks then once a week for five weeks to observe/assess all body systems, with emphasis on the genito-urinary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety, pain management as applicable and to administer IV antibiotics via midline (is an 8-12 centimeter (cm) catheter inserted in the upper arm with the tip located just below the underarm). A review of Patient 5’s nurse progress notes dated from 2/15/23 to 2/21/23, indicated that visiting skilled nurse administered heparin and normal saline flush to patient 5’s right upper arm midline before and after each use for IV antibiotics medication. Upon further review, there was no indication of documented evidence of physician’s order for heparin and saline flush was obtained from the physician. During an interview with the DPCS on 2/26/23, at 11:00 a.m., She stated that the visiting nurse should obtain an order for heparin flush from the doctor or clarification should have been also made from the doctor. A review of home health agency’s policy and procedure titled “Physician Communications/Documentation of Physician’s Orders”, updated 4/17/2022, indicated that the agency will identify when staff are to communicate with a patient’s physician, and on what forms the communications are to be documented and to ensure coordination of patient care through timely communication of changes in patient care orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurse (SN) failed to obtain a physician’s order for pain medication and communicate to the physician regarding patient’s change in condition for one of 7 sampled patients (Patient 4). For Patient 4, the skilled nurse failed to notify physician regarding complaint of pain from the left hip and left leg for seven consecutive days (from 1/15/23 to 1/21/23). This deficient practice places the patient at a potential risk for ineffective pain management that could affect her overall health status. A review of Patient 4's start of care (SOC) date of 1/11/2023 and certification period of 1/11/23 to 3/11/23, indicated a diagnosis of unspecified open wound of scalp. A review of Patient 4's plan of care (POC) and skilled nursing orders dated from 1/11/23 to 3/11/23, included an order for the skilled nurse visit of once a week for thirteen weeks to observe/assess all body systems, with emphasis on the integumentary system, and report to physician any significant finding, instruct patient on diet, disease processes, medications, home safety and pain management as applicable. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/25/23, at 10:00 a.m., Patient 4 was comfortably sitting in her reclining chair and in no apparent distress. Patient 4 stated she does not have any concerns currently, she stated that sometimes her left hip and left leg are painful, but it is only mild to moderated. Patient 4 stated she told to the visiting nurse regarding it, and she was told to rest her left hip and left leg. Patient 4 stated she does not have any pain medication. During a concurrent review of Patient 4’s clinical records on 2/26/23, at 10:30 a.m., with the DPCS, the skilled nurse (SN) progress notes dated from 1/15/23 to 1/21/23 indicated that Patient 4’s left hip and left leg pain were relieved by rest and medication, however, there was no pain medication ordered by the physician indicated in plan of care (POC) or active medication list or any documented evidence that SN reported to the physician of Patient 4’s left hip and left leg pain. DPCS stated that she does not know why the SN included medication in her nursing notes. DPCS stated that she should communicate with the doctor regarding patient 4’s pain so it could be address immediately. A review of home health agency’s policy and procedure entitled, “Significant Change in Condition Requiring Change in Plan of Care”, updated 3/30/2005, indicated that a professional and individualized plan of care shall be developed for each patient who is experiencing a significant change in condition and professional members of the healthcare team are expected to promptly notify the patient’s physician regarding changes in the patient’s condition which are enough to require change in the plan of care.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the visiting nurse failed to ensure patient caregiver(s) received an ongoing education and training for one of seven sampled patients (Patient 1) with an open wound. The deficient practice has the potential for the patient's wound care and treatment will not be implemented that could delay healing and intervention. A review of Patient 1's Plan of Care (POC) for the certification period from 2/16/23 through 4/16/23, indicated the start of care (SOC) date was 2/16/23, with diagnosis that included urinary tract infection (infection in the kidneys, bladder and urethra). The POC indicated the Skilled Nurse (SN) was to visit three times a week for two weeks, twice a week for one week, once a week for six weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to provide wound care to Stage II sacral pressure sore as follows: cleanse with normal saline, pat dry, apply Calmoseptine and cover with Tegaderm dressing. On 2/25/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS (director of patient care services). Patient 1 was alert and oriented and lying in bed. Patient 1 had a Stage II sacral pressure sore with no drainage or odor. Caregiver 1 was asked on how she provide wound care as instructed by the visiting nurse, she stated she was instructed by the visiting nurse to do the following:, cleanse with Normal Saline, pat dry and apply Calmoseptine ointment and leave open to air. A further review of Patient 1's clinical record indicated there was no documented evidence the visiting nurse provided patient teaching on how to provide wound care as ordered with a return demonstration by the patient/caregiver to validate teaching. On 2/26/23, at 1 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated she could not find any documented evidence that the visiting nurse provided wound care teaching to the patient and caregiver and a return demonstration for the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.